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Review ArticleRev. Latino-Am. Enfermagem2017;25:e2908DOI: 10.1590/1518-8345.1841.2908

www.eerp.usp.br/rlae

Procedures for measuring and verifying gastric tube placement in

newborns: an integrative review

Flávia de Souza Barbosa Dias1

Suellen Cristina Dias Emidio2

Maria Helena Baena de Moraes Lopes3

Antonieta Keiko Kakuda Shimo4

Ana Raquel Medeiros Beck4

Elenice Valentim Carmona4

Objective: to investigate evidence in the literature on procedures for measuring gastric tube insertion

in newborns and verifying its placement, using alternative procedures to radiological examination.

Method: an integrative review of the literature carried out in the Cochrane, LILACS, CINAHL,

EMBASE, MEDLINE and Scopus databases using the descriptors “Intubation, gastrointestinal” and

“newborns” in original articles. Results: seventeen publications were included and categorized as

“measuring method” or “technique for verifying placement”. Regarding measuring methods, the

measurements of two morphological distances and the application of two formulas, one based

on weight and another based on height, were found. Regarding the techniques for assessing

placement, the following were found: electromagnetic tracing, diaphragm electrical activity, CO2

detection, indigo carmine solution, epigastrium auscultation, gastric secretion aspiration, color

inspection, and evaluation of pH, enzymes and bilirubin. Conclusion: the measuring method using

nose to earlobe to a point midway between the xiphoid process and the umbilicus measurement

presents the best evidence. Equations based on weight and height need to be experimentally

tested. The return of secretion into the tube aspiration, color assessment and secretion pH are

reliable indicators to identify gastric tube placement, and are the currently indicated techniques.

Descriptors: Intubation, Gastrointestinal; Infant, Newborn; Nursing.

1 Doctoral student, Faculdade de Enfermagem, Universidade Estadual de Campinas, Campinas, SP, Brazil.2 Doctoral student, Faculdade de Enfermagem, Universidade Estadual de Campinas, Campinas, SP, Brazil. Scholarship holder at Coordenação de

Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Brazil.3 PhD, Full Professor, Faculdade de Enfermagem, Universidade Estadual de Campinas, Campinas, SP, Brazil.4 PhD, Professor, Faculdade de Enfermagem, Universidade Estadual de Campinas, Campinas, SP, Brazil.

How to cite this article

Dias FSB, Emidio SCD, Lopes MHBM, Shimo AKK, Beck ARM, Carmona EV. Procedures for measuring and verifying gastric

tube placement in newborns: an integrative review. Rev. Latino-Am. Enfermagem. 2017;25:e2908. [Access ___ __ ____];

Available in: ____________________. DOI: http://dx.doi.org/10.1590/1518-8345.1841.2908.

URL

daymonth year


2 Rev. Latino-Am. Enfermagem 2017;25:e2908.

Introduction

Insertion of Gastric Tube (GT) in Newborns (NB)

hospitalized in the Neonatal Intensive Care Unit (NICU)

is one of the most commonly performed nursing

procedures. It is indicated for gastric decompression,

administration of medications, and mainly for feeding

the gastric tube process, and despite being a standard

procedure for nurses working in the NICU, it is not

risk free and involves decisions that may compromise

patient safety(1).

Some of the important aspects to increase safety

in using GT in newborns involve care in measuring the

insertion length, assessing placement/positioning of the

distal end of the tube, and in maintaining its correct

positioning(1). Serious respiratory complications may

occur due to bronchopulmonary aspiration of gastric

contents or inadequate tube placement reaching the

respiratory tract. Intestinal absorption problems and

alimentary intolerance related to GT positioning in the

pylorus or duodenum can also occur. Moreover, difficulties

encountered in the trajectory can cause puncture injuries

to the esophagus or respiratory tract(2). The occurrence

of errors in GT placement is very frequent: studies

show proportions of 47.5 to 59% inadequate placement

between neonatal and pediatric patients(3-4).

The nurse’s decision-making process during gastric

tube procedure begins with the choice of an effective

method that has a strong association with measuring

the actual tube route from the nostril or oral cavity to

the body of the stomach, passing through the entire

length of the esophagus(1).

After choosing the measuring method and

performing the insertion, it is necessary to verify that

the distal end of the tube has reached the body of the

stomach, as well as whether all the distal orifices are

within the gastric cavity in order to prevent fluid leakage

into the esophagus or duodenum(1).

Radiological examination of the chest and abdomen

is considered the gold standard verification technique,

since it allows visualization of the GT route and the

positioning of its distal end. Despite presenting the

most reliable result, this technique is costly and is

not commonly used in neonatal clinical practice for

this reason, as the GT is often replaced, and repeated

exposure to radiation can be dangerous(2). Another

limitation is the fact that this test is only effective at the

moment it is performed, since tube displacement can

happen immediately after(2,5), thus requiring the use of

other techniques to assess tube placement other than

radiological examination.

In this integrative review, we sought evidence

that may assist nursing assistants in the decision-

making process regarding gastric tubes in newborns

in the NICU, given the importance of always choosing

the best health practices aiming at patient safety. Thus,

this study aimed to investigate evidence in the literature

on procedures for measuring gastric tube insertion in

newborns and verifying its placement, using alternative

procedures to radiological examination.

Method

This is an integrative review of the literature which

seeks to synthesize results from previous studies on

the proposed subject(6). Integrative reviews have the

potential to evidence comprehensive understanding of

specific issues and to identify gaps in knowledge. This

is a very useful method for nurses who are in clinical

practice and wish to perform nursing assistance based

on scientific evidence(7-9).

The steps followed in elaborating this review

were: establishing the research question, conducting

a literature search, evaluating data, analysing the

included studies, interpreting the results and presenting

the review(8).

The guiding question of this study was “What are

the procedures for measuring gastric tubes in newborns

and for assessing its placement, other than radiological

examination?”

The search was performed in January 2017 in

the following databases: Cochrane Library, Cumulative

Index to Nursing and Allied Health Literature (CINAHL),

Excerpta Medica dataBase (EMBASE), Literature of

Latin American and the Caribbean on Health Sciences

(LILACS), Medical Literature Analysis and Retrieval

System Online (MEDLINE) and Scopus. No time frame

for inclusion of articles was established.

The terms used in the searches were extracted

from the Health Sciences Descriptors (DeCS) and

from the Medical Subject Headings (MeSH), and

included: Intubation, Gastrointestinal and Newborns,

as well as their respective versions in Portuguese and

Spanish. Synonymous terms suggested by EMBASE at

the time of the search were also searched. In order

to delimit the search, publications with the terms

gastrostomy, pain, surgery and intubation intratracheal

were excluded for not addressing the subject of this

review. Publications contained in the references of the


3Dias FSB, Emidio SCD, Lopes MHBM, Shimo AKK, Beck ARM, Carmona EV.

selected studies whose titles addressed the research

subject were also investigated.

Article selection was carried out by two researchers

independently, and inclusion criteria were: original

studies published in-full that address, in the title or

abstract, gastric tube measurement procedures and/

or techniques for assessing its placement, and which

included newborns in the studied sample; studies

published in Portuguese, English or Spanish. Theses

and dissertations, pilot studies, review articles, case or

experience reports, letters, editorials and publications

where the method was not clearly described were

excluded. PRISMA recommendations(10) were followed

for the study selection, as shown in Figure 1.

A form with the following items was elaborated by

the authors for developing the analysis: bibliographic

reference, level of evidence, language, country of origin,

main researcher’s training, database, objective, study

design, ethical considerations, subjects, main results,

conclusion and limitations.

Seven (7) levels of classification were considered

to categorize the level of evidence: level 1 - systematic

review or meta-analysis of controlled clinical trials; level

2 - well-delineated randomized controlled clinical trial;

level 3 - controlled clinical trial without randomization;

level 4 - well-delineated cohort or case-control studies;

level 5 - systematic review of qualitative and descriptive

studies; level 6 - descriptive or qualitative studies; and

level 7 - opinion of authorities or experts(11). The results

were analyzed and presented in a descriptive way.

As this is an integrative review, it was not necessary

to request approval from the Ethics Committee to carry

out the study. We declare no conflicts of interest.

Records identified throughsearching the databases

(n=785)

Iden

tifica

tion

Sele

ctio

nEl

igib

ility

Incl

usio

n

Records identifiedfrom other sources

(n=3)

Records after excluding duplicates(n=612)

Tracked reports(n=52)

Excluded reports(n=560)

Full articlesexcluded

(n=35)

Qualitative studies includedin the review

(n=0)

Quantitative studies includedin the review

(n=17)

Full articles evaluated foreligibility

(n=17)

Figure 1 - Flowchart of the identification, selection and inclusion process of the studies, elaborated based on the

PRISMA recommendation(10).

Results

The number of publications found in the investigated

databases, as well as other sources included in this

review are presented in Figure 2.

The 17 articles included in the review were all

published in English between 1987 and 2016. The

majority of the studies were carried out in the United

States (n = 13), the main authors had training in nursing

(n = 11) and medicine (n = 6). The included studies were

classified into two categories for data analysis: “Methods

for measuring gastric tube” and “techniques for assessing

gastric tube placement”. Characterization of the articles

considering the level of evidence is presented in Figure 3.



Database Interface Retrieved* Included*

LILACS Biblioteca virtual de Saúde – BVS Bvsalud.com

11 0

MEDLINE National Center for Biotechnology Informationncbi.nlm.nih.gov/pubmed

462 11

CINAHL EbscoHostweb.a.ebscohost.com

77 9

EMBASE Embase.com 9 0

Scopus Scopus.com 226 7

Cochrane Onlinelibrary.wiley.com/cochranelibrary 0 0

Other sources List of references from the articles 3 3

* Some publications were repeated in more than one database

Figure 2 – Number of publications found in the databases and included in the study.

N Title Authors Year Journal Country Level of evidence

1(12) Gavage tube insertion in the premature infant

Weibley TT, Adamson M, Clinkscales N, Curran J, Bramson R

1987 MCN - The American Journal of Maternal Child Nursing

United States 3

2(13) Orogastric tube insertion length in very low birth weight infants

Gallaher KJ, Cashwell S, Hall V, Lowe W, Ciszek T

1993 Journal of perinatology: official journal of the California Perinatal Association

United States 6

3(14) Indicators of feeding-tube placement in Neonates

Metheny NA, Eikov R, Rountree V, Lengettie E.

1999 Nutrition in Clinical Practice United States 6

4(15) Methods to test feeding tube placement in children

Westhus N 2004 MCN – The American Journal of Maternal Child Nursing

United States 6

5(16) Gastric tube placement in young children

Ellett ML, Croffie JM, Cohen MD, Perkins SM

2005 Clinical Nursing Research United States 6

6(17) Litmus tests for verification of feeding tube location in infants: evaluation of their clinical use

Nyqvist KH, Sorell A, Ewald U

2005 Journal of Clinical Nursing Sweden 6

7(18) Predicting internal distance to the stomach for positioning nasogastric and orogastric feeding tubes in children

Beckstrand J, Ellett MLC, McDaniel A

2007 Journal of Advanced Nursing

United States 6

8(19) Electrocardiographic guidance for the placement of gastric feeding tubes: a pediatric case series

Green ML, Walsh BK, Wolf GK, Arnold JH

2011 Respiratory Care United States 6

9(20) Predicting the insertion length for gastric tube placement in neonates

Ellett MLC, Cohen MD, Perkins SM, Smith CE, Lane KA, Austin JK

2011 JOGNN – Journal of Obstetric, Gynecologic and Neonatal Nursing

United States 2

10(21) Verification of an electromagnetic placement device compared with abdominal radiograph to predict accuracy of feeding tube placement

Powers J, Luebbehusen M, Spitzer T, Coddington A, Beeson T, Brown J, Jones D

2011 JPEN – Journal of Parenteral and Enteral Nutrition

United States 6

11(22) A weight-based formula for the estimation of gastric tube insertion length in newborns

Freeman D, Saxton V, Holberton J

2012 Advances in Neonatal Care Australia 6

12(23) Increasing the safety of blind gastric tube placement in pediatric patients: the design and testing of a procedure using a carbon dioxide detection device

Gilbert RT, Burns SM 2012 Journal of Pediatric Nursing United States 3

13(24) Comparing bedside methods of determining placement of gastric tubes in children

Ellett MLC, Cohen MD, Croffie JMB, Lane KA, Austin JK, Perkins SM

2014 Journal for Specialists in Pediatric Nursing

United States 6

14(25) Confirmation of gastric tube bedside placement with the sky blue method

Imamura T, Maeda H, Kinoshita H, Shibukawa Y, Suda K, Fukuda Y, Goto A, Nagasawa K

2014 Nutrition in Clinical Practice Japan 6

15(26) The pH of feeding tube aspirates from critically ill infants

Meert KL, Caverly M, Kelm LM, Metheny NA.

2015 Nutrition in Critical Care United States 6

16(27) Accuracy of a weight-based formula for neonatal gastric tube insertion length

Nguyen S, Fang A, Saxton V, Holberton J

2016 Advances in Neonatal Care Australia 6

17(28) Use of temporary enteral access devices in hospitalized neonatal and pediatric patients in the United States

Lyman B, Kemper C, Northington L, Yaworski JA, Wilder K, Moore C, Duesing LA, Irving S

2016 JPEN – Journal of Parenteral and Enteral Nutrition

United States 6

Figure 3 - Characterization of publications and levels of evidence of the articles included in the review.



Methods for measuring the gastric tube

Among the articles that addressed GT measurement,

four were observational studies(13,18,22,27) and two were

experimental studies(12,20), and were mostly published

in nursing journals. With regard to ethical aspects,

only one article(12) did not report having submitted the

study to ethical appreciation. Figure 4 briefly describes

each of these studies, addressing the design, objective,

population sample, main results and limitations.

The methods described in the literature for GT

measurement in NBs include the NEX and NEMU

morphological measures. NEX (Nose, Earlobe, Xiphoid)

corresponds to the distance measured from the tip of

the nose to the earlobe to the xiphoid appendix, while

NEMU (Nose, Earlobe, Mid-Umbilicus) corresponds to

the distance measured from the tip of the nose to the

earlobe to a point halfway between the xiphoid process

and the umbilicus(12).

A method that determines the minimum insertion

length of the tube has been specifically developed for

low birth weight newborns (<1500g)(13). Minimum

insertion measures proposed in this study are 13cm for

newborns weighing less than 750g, 15cm for newborns

weighing between 750 and 999g, 16cm for newborns

weighing between 1,000 and 1,249g, and 17cm for those

weighing between 1,250 and 1,499g. Application of this

minimum insertion length method to a sample of 27 NBs

weighing less than 1,500 g showed an increase in the

proportion of correct gastric tube positioning from 62 to

86%. This method makes it possible to avoid positioning

the end of the tube above the gastreophageal junction,

thus reducing the risk of aspiration and other respiratory

complications.

In addition to these measurements, two equations

are described to estimate the insertion length of the

tube: the height-based equation(18,20) and the weight-

based formula(22). According to one of the studies(18)

selected in this review, NEX and NEMU morphological

measures do not present good predictors of the internal

measurement due to their high variability when repeated

measures are taken.

In comparing several external measurements

with internal measurement verified by endoscopy

or esophageal manometry, the results showed that

height was the best predictor for measuring the gastric

tube. The relationship between height and internal

measurement of tube passage varied according to

age; therefore, specific equations at different age

intervals were developed for calculating the insertion

measurement of the naso-orogastric tube. When these

equations were projected onto the studied sample

through computational analysis, the performance was

very promising, with success rates between 96.5 and

98.8%, depending on the infant’s age(18). However, a

major limitation of this study considering the objective

of the present review was the small participation of NBs,

with only 1% in the studied sample.

A study comparing the accuracy/success rates of

the NEX, NEMU methods and the height-based equation

(ARHB - Age Related, Height Based) performed two

different analyzes(20). In the first analysis, the end of the

tube visualized in the stomach, pylorus or duodenum

was considered as correct positioning, and the accuracy

ratio was 60.6% for NEX, 92.4% for NEMU and 100%

for ARHB. NEMU and ARHB measurements were

significantly higher than NEX (p<0.001). In the second,

more restrictive analysis, only the tubes visualized

in the stomach were considered to be positioned

correctly. The results of the second analysis were:

60.6% accuracy for NEX, 90.9% for NEMU and 78% for

ARHB. Although no significant difference (p = 0.615)

between NEX and ARHB rates were found in the second

analysis, it can be noticed that all errors presented by

NEX measure occurred by placing the tube above the

gastroesophageal junction, while the errors presented

by the ARHB measure were always below the pylorus.

This difference is relevant with respect to the type of

error, its risks and complications. During this study, the

authors also developed a new ARHB equation adjusted

for use in newborns between 35 and 56.5cm in length for

measuring the nasogastric tube: 1.95 +0.372x[height in

cm]. It was not possible to develop a new equation for

orogastric route in newborns with the mentioned length

due to the small number tubes inserted by this route in

the sample (10.4%)(20).

Another method described in the literature is the

weight-based equation(22). The authors justify the need

to create this method based on the fact that height is not

an easily accessible measure in neonatal clinical practice,

while in contrast weight is a more viable predictor as it is

checked daily and used as a reference for several clinical

applications such as calculation of drug dosages, diets

and estimating catheter insertion, among others. In

this study, 218 radiological images were analyzed, and

by way of using a linear regression analysis, formulas

for orogastric (3x[weight in kg]+12) and nasogastric

tubes (3x[weight in kg]+13) were developed. When

designing such formulas in the studied sample based on

computational analysis, it was possible to predict 100%

of poorly placed nasogastric and 60% orogastric tubes.

The lower rates found in orogastric tubes may be related

to the fact that the tubes move more when positioned

in the oral cavity.

The use of the weight-based formula as an auxiliary

method to NEMU in GT insertion was described in another



study(27), however, the result was lower than expected, with

16% of tubes being incorrectly positioned (above or near

the gastroesophageal junction). The authors suggest that

this result is justified by the fact that the formula was not

fully incorporated by the nursing team as a measurement

strategy. When individually analyzing the 31 cases of

incorrect positioning, 22 (71%) of them would have been

avoided if the formula had been calculated and used.

N Design Objective Population sample Main results and limitations

1(12) Experimental Compare error rates of NEX* and NEMU† measurements, visualized by x-ray

60 PTRNs‡ NEX*: 55.6% error;NEMU†: 39.3% error.NEMU† has greater reliability than NEX*, however with no statistical significance. 50% of the sample was excluded from the analysis due to the impossibility of data collection

2(13) Descriptive Determine the minimum insertion length of the GT§ in low birth weight NB||, after the analysis of 188 x-rays of GT§

27 NBs|| <1500g Presents a table with minimum insertion measures, according to NB|| weight.

Small sample, only orogastric positioning was evaluated

7(18) Descriptive Compare the anatomical-morphological distances with the inner distance of the esophagus and develop an equation based on height to estimate exterior insertion length of the GT§

498 children (5 NBs||) NEX* and NEMU† measurements were not shown to be good predictors of esophageal distance.The best predictor was height.Height-based and age-differentiated (ARHB¶) equations were developed to estimate GT length.

Negligible number of NB|| in the sample

9(20) Experimental Compare success/accuracy of gastric placement among NEX*, NEMU† and ARHB¶

methods.

173 NBs|| NEX*: 60.6% success; ARHB¶: 78% success; NEMU†: 90.9% success. Recommends that NEX* is no longer used. Introduces a new ARHB¶ equation adjusted to NB||.

ARHB¶ cannot be randomized in 34% of cases

11(22) Descriptive Develop an equation based on the weight of the NB|| to estimate exterior length of insertion of the GT§, after the analysis of 218 x-rays of GT§

87 NBs|| Introduce formulas for nasal and orogastric tubes, suggesting that this new method be used in combination with the current method.

Only one radiologist evaluated the images, and no prospective study was performed for the application of the formula

16(28) Descriptive Describe the correct positioning rate using the weight-based formula as an auxiliary method

107 NBs|| 84% of the tubes were correctly positioned, 12.5% were at the limit and 3.6% were high.Only one radiologist evaluated the images

*(Nose, Earlobe, Xiphoid): distance measured from the tip of the nose to the earlobe to the xiphoid process; †(Nose, Earlobe, Mid-Umbilicus): distance measured from the tip of the nose to the earlobe, a point halfway between the xiphoid process and the umbilicus; ‡pre-term newborns; §gastric tube; ||newborns; ¶(Age Related, Height Based): height-based equation classified by age.

Figure 4 - Studies on gastric tube measurement methods.

Techniques for assessing gastric tube placement

Of the 11 studies classified in this category, 10

were observational studies that investigated alternative

techniques to visualizing radiological imaging, established

as the gold standard to verify GT placement. Such

alternative techniques have the objective of improving

patient safety, achieving a reduction of radioactive

exposure without increasing the risk and complications

related to incorrect tube placement. The studies included

in this category are described in detail in Figure 5.

The techniques investigated to verify GT positioning

in NBs include: gastric secretion aspiration; epigastric

region auscultation; checking aspirated secretion’s pH,

pepsin, trypsin and bilirubin; secretion color; presence

of CO2 test; acid test with litmus paper, reading

diaphragm’s electrical activity; electromagnetic tracing

and the use of indigo carmine at 0.01%.

The diagnostic accuracy tests used in three

studies(15,16,24) included in this review were always

compared to radiological examination. However, one

study(15) evaluated the test accuracy in identifying

correctly positioned tubes, and two other studies(16,24)

evaluated the accuracy in identifying incorrectly

positioned tubes. This prevents the simple comparison

of the values between the three studies.



The study that investigated the accuracy of correctly

positioned tubes found that the use of pH evaluation

along with color evaluation is the safest technique to

confirm correct positioning, considering pH <6.0 and

translucent greenish and brownish colors(15).

For studies that performed accuracy tests for

incorrect positioning of the tube(16,24), the most

important value to be considered is positive predictive

value, since the use of the investigated techniques

occurs at the bedside and represents the proportion

of tests that assertively indicate incorrect positioning

of the tube. The indicator with the highest positive

predictive value (66.7%) was absence of aspirated

secretion. The second most important indicator was

the pH test, which presented positive predictive values

ranging from 20 to 25%.

The accuracy of capnography in identifying incorrect

positioning of the GT cannot be confirmed as there were

no placements in the respiratory tract(16,24), and also

because it is possible to detect the presence of CO2 in

the oral cavity, oropharynx, esophagus and stomach(23).

The evaluation of bilirubin presence was not a

reliable indicator to identify incorrect positioning, since

N Designand population sample Investigated techniques Main results and limitations

3(14) Descriptive; 39 newborns pH, Pepsin, Trypsin, Bilirubin and color of the secretion of 88 tubes correctly positioned in the stomach

pH 4.32(±0.2); Pepsin 60.4(±6.3); Trypsin 6.8 (±1.4); Bilirubin 0.35 (±0.1). Col-or of the secretion: 68.2% off white; 22.7% greenish; 4.5% translucent; 2.3% brown. 2.3% yellowish.pH, trypsin and bilirubin values are similar to those described in the literature for the adult population, while the pepsin value found in newborns is much lower. Small sample

4(15) Descriptive; 56 children, between newborns and up to 14 years of age

pH (<6.0), Pepsin (>20), Trypsin (<50) and secretion color

Sens* Spec† PPV‡ NPV§

pH 77.6% 85.7% 97.4% 35.2%

Pepsin 69.4% 71.4% 94.4% 25%

Trypsin 90% 71% 96% 50%

Color 92.5% 71.4% 94.4% 62.5%

pH+Cor 70% 100% 100% 36.8%

pH 4.1(±3.2); Pepsin 215.4 (±32.0); Trypsin 10.6 (±2.9). The colors that were identified as gastric positioning were: whitish, translucent, greenish and brownish.It was not specified how many newborns participated in the sample. The value of Pepsin was high because it contained many children in the sample of 1 year (42%).

5(16)|| Descriptive; 72 children, between newborns and up to 7 years of age

pH (5.0 limit), Bilirubin (5mg/dl limit) and Capnography, compared to radiological examination

Sens* Spec† PPV‡ NPV§

pH 53.9% 61.8% 25% 85%

Bilirrubin 0% 96.6% 0% 96.6%No tubes were present in the respiratory tract (according to the radiological examination). The CO2 reading was 0mmHg in 71 samples, and it was 2mmHg in only one.The subjects had already used the tube when they were included in the study.

6(17) Descriptive; 60 newborns Acidity test using litmus paper

97% Positive tests, 3% Negative tests. No comparison was made with another method.Litmus paper is limited for pH assessment because it only classifies the secre-tion as acidic or alkaline.

8(19) Descriptive, with case se-ries; 20 children

Catheter with embedded electrodes (EAdi¶) to evaluate the electrical activity of the diaphragm

Gastric insertion of EAdi¶, connected to the Servo-i mechanical ventilation de-vice at its proximal end (Maquet Critical Care, Solna, Sweden) allows reading of the electrical activity of the diaphragm during insertion and positioning of the catheter. The EAdi¶ device allowed for correctly identifying the placement of all tubes, when compared to the radiological examination.Small sample. High catheter cost.

it did not predict tubes positioned in the duodenal

portion(16, 24).

The use of the electromagnetic tracing device and

evaluating electrical activity in the diaphragm showed

good precision and accuracy. The major advantage of

these techniques is the possibility of real-time path

correction during tube passage, as well as avoiding

exposure to radiation, since these procedures are

presented as possible substitutes for abdominal

radiography. However, the sample of pediatric patients

was very reduced, thus making generalizations difficult;

also, both techniques are very expensive(19,21).

Administration of an indigo carmine solution (sky

blue) to check the positioning of the gastric tube is only

useful when it is possible to ensure correct positioning

of an anterior tube. In the study investigating this

method(25), the first passage of GT was always verified

by radiological imaging, and subsequent exchanges were

performed every three weeks. At the time of each change

before the tube was removed, the techniques for verifying

the presence of gastric secretion and pH were used to

confirm the positioning. The anterior tube measurement

was maintained for insertion of the new tube.

(the Figure 5 continue in the next page...)



N Designand population sample Investigated techniques Main results and limitations

10(21) Descriptive; 194 individu-als, between newborns and up to 102 years of age (12 individuals less than 1 year of age)

Electromagnetic device (EMPD**)compared to two radiological examination images

Among the pediatric patients, the EMPD** presented 99.4% agreement with the first radiological examination (simple) and 100% with the second (con-trast). 19 incorrect positions in the respiratory tract were avoided in the total sample with the use of EMPD**, 4 of them in pediatric patients.Small sample of pediatric patients. Specific training is required to read the EMPD** result.

12(23) Experimental; 42 children, between newborns and up to 18 years of age

CO2 detector device 100% accuracy in detecting CO2, however CO2 can be detected outside the airway, for example if the child cries during tube introduction.Sample selected by convenience.

13||(24) Descriptive; 276 children, between newborns and up to 17 years old (173 new-borns)

pH (5.0 limit for fasted chil-dren and 6.0 for fed infants),Bilirubin,Capnography,Gastric secretion color, Gas-tric secretion consistency,Absence of gastric residue

Sens* Espec† VPP‡ VPN§

pH>5,0†† 8.7% 92.2% 20% 81.7%

pH>6,0†† 0% 89.5% 0% 89.5%

Sem resíduo 34.9% 94.8% 66.7% 83.1%

Cor 42.5% 60% 17.5% 83.9%White, green and bronze colors may indicate correct tube placement.Secretion consistency did not prove useful for the positioning assessment.It was not possible to evaluate Bilirubin and CO2, since they did not present variability.

14(25) Descriptive; 44 newborns Sky blue method for gastric tube exchange

Administration of 0.01% indigo carmine solution immediately prior to the ex-change procedure. Positioning is considered correct when it is possible to as-pirate bluish secretion through the new tube. 94.4% showed a blue solution result. No comparison was made with another method.The long-term effects of the use of indigo carmine are not known.

15(26) Descriptive; 54 newborns pH test in situations with and without the use of gastric secretion inhibitors, in fasting and fed newborns

Regardless of the use of gastric secretion inhibitors and whether newborns were fasting or not, pH was <5.5 in 90% of cases where the tube was correctly positioned in the radiological evaluation.Small sample selected by convenience.

17(28) Descriptive; 63 institutions (1,191 children using gas-tric or enteral tube,between newborns and up to 14 years)

Description of the technique used to verify tube place-ment, according to the team’s responses to the question-naire

First choice techniques in the investigated institutions: inspection of the secre-tion (n=21), auscultation of the epigastric region (n=18), measurement of the tube (n=8), pH (n=10), X-rays (n=6). Sample selected by convenience, low reliability of the data collected as they were self-reported by the institutions

*Sensitivity; †Specificity; ‡Positive predictive value; §Negative predictive value; ||Investigated the accuracy to determine incorrect positioning; ¶Electrical Activity of the Diaphragm; **Electromagnetic Placement Device; †† Only refers to NBs included in the sample.

Figure 5 - Studies on techniques for assessing gastric tube placement.

Discussion

The first description found in the literature on NEX and

NEMU methods dating from 1978 was not included in this

review, as it did not clearly present the method described.

In this study, the authors describe using the NEX measure

in clinical practice, however, they suspected that it was not

a long enough measure, as they were not always able to

aspire gastric contents. In order to validate their hypothesis,

the authors followed some necropsies (they do not describe

how many), and observed that with the NEX method, the

distal end of the tube was at the limit of the gastroesophageal

junction, and that it was necessary to add a few centimeters

to the measurement for the distal end of the tube to reach

the body of the stomach. Thus, the authors proposed the

NEMU method and observed that the tube was correctly

positioned in necropsies using this method(29).

After this one, other studies have showed the

inferiority of the NEX measure compared to the

NEMU(12,18,20). Although the latter also represents a

measure that has high variability, the present review

indicates that it is the best evidenced method to date to

be reproduced in clinical practice.

Equations that use height(18,20) and weight(22,27)

to calculate the gastric tube insertion measure seem

to reproduce reliable results; however, the absence

of experimental studies with such methods impedes

them being used as a single reference. Therefore, it

is suggested that these equations are only used as a

supporting measure in the decision on the tube length to

be introduced, at least until studies with new evidence

are available.

For the population of NBs below 1,500g, use of

the minimum length table of the tube to be introduced

can also be indicated as an auxiliary method to avoid

positioning above the gastroesophageal junction(13). It

should be noted that this table should only be used for

the oral route of insertion.



Verifying GT positioning in NBs is a process that

requires nurses’ attention due to the unavailability of

precise techniques such as electromagnetic tracings or

diaphragm electrical activity evaluation, as well as the

impossibility of performing a radiological examination at

each tube exchange due to the costs and risks involved(1,2).

Thus (and the findings of this review confirm), nurses

must use several strategies simultaneously, with the

objective of increasing the safety of the procedure.

The most easily accessible indicator is gastric

secretion return to the tube aspiration, which

presented good results in the accuracy tests of one

of the reviewed studies(24). Recommendations from

international agencies(30-32) also indicate pH (<5.0)

evaluation of aspirated secretion as a technique for

verifying GT positioning. Other studies(15-16) suggest

that combining pH assessment with secretion coloration

(whitish, translucent, greenish or brownish) makes the

assessment even safer, since these are the indicators

with the best results among the accuracy tests.

The use of gastric shields (histamine-2 receptor

antagonists and proton pump inhibitors), as well as

continuous infusion of milk formula and the use of sterile

water to wash the catheter raise questions about the

safety of the aforementioned combined evaluation, since

they could increase gastric pH(2). However, the reviewed

studies comparing gastric pH in NBs and infants did not

find significant differences between those who received

and did not receive these medications, as well as those

who were fed continuous infusion, gavage, or those who

underwent fasting(2,16,24,26).

In the absence of gastric secretion return, the

risk of improper placement increases. In this situation,

nurses may insist on obtaining a sample, performing

movement maneuvers with the newborns and injecting

air (not more than 2ml). Since it is possible that the tube

is in direct contact with the mucosa, these maneuvers

can favor its displacement and attainment of secretion.

If it is still not possible to aspirate secretion through

the catheter after such maneuvers, the possibility of

changing the catheter or performing a radiological

examination can be discussed to visualize the path and

positioning of the distal end(31).

The use of abdominal ultrasonography to verify

GT placement has been shown to be a useful and

effective technique in adults with high sensitivity and

specificity; attaining 98.3 and 100%, respectively, when

compared with the results of conventional radiological

examination(33). Its use in verifying the location of the

end of the GT has been recommended in adult patients

instead of radiological examination since it is a simple

and fast technique, in addition to the advantage of not

exposing the patient to radiation(34-35). A study carried out

in two intensive care units with 14 neonatal and pediatric

patients also demonstrated the efficacy of ultrasound to

evaluate jejunal tube placement in these patients(36).

A pilot study published as a letter(37), which was

not part of this review sample, reports that the use of

ultrasonography to verify GT positioning in NBs is not

a reliable technique, as it was only possible in one

of the 10 cases studied to visualize the distal end of

the tube in the stomach. However, all had the gastric

position confirmed by the pH test (<5.5)(37). Considering

the small sample size of the cited study and data that

contradict promising results in adults, it is necessary to

perform more research with ultrasound in NBs.

Despite care for tube maintenance not being

the subject of this review, it should be pointed out

that monitoring the external length can be used as a

supporting measure in maintenance of tube placement

and patient safety, especially when dealing with long-

term tubes. In the description of an implementation

protocol for tube maintenance in NBs(5) and in an

integrative review(38), the authors recommend that the

external length should be checked and recorded in the

medical record and/or recorded on the tube in a visible

manner, always confirming it before use. However,

it is relevant to consider that keeping the external

length stable does not eliminate the risk of internal

displacement.

In this review, it was identified that the procedure

of introducing air through the tube and auscultating

the epigastric region is the second chosen method of

American nurses to confirm gastric positioning(28), which

is also observed in the clinical practice of the authors

considering their action and teaching fields. However,

literature indicates that it is possible to listen to the air

bubbles in the epigastric region, regardless of whether

the end of the tube is located in the stomach, esophagus

or respiratory tract. Therefore, the use of this technique

is discouraged and should be banned(1,16,29-32,38).

As a contribution to clinical practice, the findings of

this integrative review support, recommending the use

of the NEMU method (with possible confirmation by the

use of formulas based on weight or height) in order to

reduce risks and complications related to the procedure

since it presents a smaller proportion of error, and

the combined performance of positioning verification



techniques prior to each GT use (gastric secretion

aspiration with pH and color assessment).

Another integrative literature review(38) addressing

this subject was found, however, it also included pediatric

patients up to 18 years of age. We also found literature

reviews(1-2) that did not present a detailed description of

the method and included studies. Thus, the difference in

the present integrative literature review was to gather

evidence on the methods for measuring and confirming

GT placement in NBs. Among the 17 studies of this

integrative review, only one well-delineated randomized

controlled clinical trial, two randomized controlled trials

and 14 descriptive studies were found. No systematic

reviews or meta-analyses were found.

Given the specificities of the age group in question

and gaps in the literature, it is considered relevant to

emphasize that there is a need for experimental research

on the methods already described for measuring the

tube and verifying its positioning in order to offer

support and safety to neonatal clinical practice, as well

as for the technological development of devices with

affordable cost.

The results of the present study were limited by the

lack of research that specifically focused on neonates,

as well as by the predominant number of descriptive

studies which made it impossible to synthesize findings

with high levels of evidence to innovate clinical practice.

Conclusion

Regarding methods for measuring gastric tube

for insertion in newborns, implemented morphological

distances present high variability, which compromises

their reliability. The use of the NEX measurement greatly

increases the risk of positioning the tube tip above the

gastroesophageal junction, and should be replaced by

the NEMU measurement. New measurement methods

based on weight and height have been developed, but

clinical trials are still needed to test their efficacy.

Regarding the choice of technique for placement

verification after insertion, no other method is available

as safe as the radiological examination of the chest and

abdomen. The use of electromagnetic tracing seems

promising and deserves further investigation in newborn

subjects. However, it is still expensive and inaccessible

in the Brazilian context.

Evidence indicates that the absence of secretion

return to tube aspiration is a simple and sensitive

method, and therefore it should be seen as a strong

indicator of inadequate positioning. Moreover, pH

evaluation and secretion staining for verification of

gastric placement are the indicators that present the

best results in accuracy tests when compared with

radiological examinations.

Concerning implications for clinical practice, there

is still a lack of evidence to establish safe protocols,

as some current procedures should have already been

abandoned as pointed out in the literature, such as the

use of NEX for measuring the tube and epigastric region

auscultation to confirm its positioning.

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Received: Sept. 4th 2016

Accepted: Apr. 6th 2017

Copyright © 2017 Revista Latino-Americana de EnfermagemThis is an Open Access article distributed under the terms of the Creative Commons (CC BY).This license lets others distribute, remix, tweak, and build upon your work, even commercially, as long as they credit you for the original creation. This is the most accommodating of licenses offered. Recommended for maximum dissemination and use of licensed materials.

Corresponding Author:Flávia de Souza Barbosa DiasUniversidade Estadual de Campinas. Faculdade de EnfermagemRua Tessália Vieira de Camargo, 126Cidade Universitária Zeferino VazCEP: 13083-887, Campinas, SP, BrasilE-mail: [email protected]

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content/91/5/F388.2. doi:10.1136/adc.2005.088476.

38. Clifford P, Heimall L, Brittingham L, Finn Davis

K. Following the evidence: enteral tube placement

and verification in neonates and young children. J

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2016];29(2):149-61. Available from: http://journals.

lww.com/jpnnjournal/pages/articleviewer.aspx?year

=2015&issue=04000&article=00013&type=abstract.

doi:10.1097/JPN.0000000000000104.

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